Q&A with Mike Brady from Baby Milk Action

Mike Brady is networking coordinator at Baby Milk Action, a non-profit organisation which aims to save lives and to end the avoidable suffering caused by inappropriate infant feeding. It is the UK member of the International Baby Food Action Network (IBFAN), a network of over 200 citizens groups in more than 100 countries. Mike was our Q&A guest in December 2010.

Baby Milk Action's slogan is: Protecting breastfeeding - Protecting babies fed on formula. It is perhaps best known for promoting a boycott of Nestlé, but also works with national governments and international bodies on regulations and marketing standards.

Mike: I would like to thank Mumsnet for the opportunity to answer some of the questions posted to the forum. The following were selected for me to answer. These answers have been edited as I went into chat mode in my initial effort. Longer versions of all these answers are available on my blog on the Baby Milk Action website.

Q.Lowercase: What drives you to carry on campaigning? And what has been the single most positive or encouraging change you have seen during your campaign?

A. Mike: Strategically, the most encouraging change has been the progress in bringing the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant Resolutions of the World Health Assembly into legislation - and seeing how breastfeeding rates have been recovering in some of the countries where this has been achieved.

There have been many other victories, big and small, so it is difficult to choose any particular one. In the UK, it was great to pick up some powdered infant formula in the supermarket earlier this year to find labels now warn that it is not sterile. We are still working for companies to bring their instructions fully into line with the Department of Health guidance on how to reduce the risks from possible contamination with harmful bacteria, but at least this important information is there as a direct result of our campaigning.

Internationally, having worked in Malawi, one of the poorest countries in the world, I was particularly pleased when we forced Nestlé to translate its formula labels into the national language after it had resisted this for years on the grounds of 'cost restraints'. What drives me to carry on is knowing that we are helping to save the lives and reduce the suffering of the most vulnerable people on the planet - newborn babies. With your help.

Q. Ceidlihgirl: Bottlefeeding mums perceive Baby Milk Action to be anti-formula. While this may not be the case, that perception will affect the credibility of anything you say. Does your organisation need a makeover?

A.Mike: I'm not sure what we need to do by way of a makeover when our site and materials explicitly state that we are not anti-formula and our slogan is, 'Protecting breastfeeding - Protecting babies fed on formula'. I have seen the industry suggest we are anti-formula and Nestlé has also falsely told people that we are trying to stop formula being sold, which is untrue - amongst other things we are trying to make it cheaper for mothers and carers who use it. Formula in the UK covers a wide price range. This is not because the more expensive formula is better than the cheaper formula, it has much more to do with how the company is placing its product in the market and how much its spends on advertising and promotion.

I asked the Advertising Standards Authority (ASA) to investigate whether Aptamil really is the 'best' formula when this claim appeared in an advertisement for the follow-on milk, as well as a claim used about the added ingredient, Immunofortis. The ASA found the company could not prove its claims and warned the company not to repeat them. There is a lot of other work Baby Milk Action does to protect babies fed on formula, from campaigning for levels of pesticides in formula to be reduced, to campaigning for improved composition and labelling.

Q.Lagrandissima: Do you work with schools to raise awareness of issues around the formula industry? Do you think it might be useful to educate future parents at an early age about the pros and cons of formula and breastfeeding?

A.Mike: Infant feeding is something that is covered in the school curriculum - and information about the World Health Assembly marketing requirements was added to this after one of our directors raised it with a previous government. But we are not health educators ourselves so, other than our new educational resource on infant formula, our focus is on how companies market breastmilk substitutes.

We do have materials for schools and the Nestlé boycott plays a key role in interesting students. We worked with a development education organisation a while ago to produce a school education pack on issues about understanding public relations, from corporations and campaigning organisations, which is still available as free downloads on our site. This includes analysing the famous picture of a mother in Pakistan with a breastfed son and bottle-fed daughter, though the pack is not specifically on infant feeding issues.

Q. FrozenNorthpole: If there is one message you would like the 18-21 year old parents of the future to receive about breastfeeding, what would it be?

A.Mike: Everyone on Mumsnet probably already knows the World Health Organisation and Department of Health recommends exclusively breastfeeding for six months and then to continue to breastfeed while introducing complementary foods. Sometimes that is described as the 'optimum', but really the evidence is that it's the feeding regime that fits with the way we have evolved as a species.

The one message that I would like all 18-21 mums and dads of the future to understand is that any period of breastfeeding will help a child's development and the impact is not totally undone if formula is introduced at some point. We really need to take the heat out of the breastfeeding vs formula argument that blows up too often, because it drives people into one camp or the other. It seems some people think that the choice is between breastfeeding exclusively for six months, or exclusively using formula instead.

Even if using formula, some feeds can still be breastfeeding as long as a mother and baby wants - being aware, of course, that introducing feeding bottles interferes with lactation and reduces a mother's milk supply (and it not recommended if HIV is an concern).

Q.Tiktok: How does Baby Milk Action explain that having concerns about formula is not the same as judging mothers who use it?

A.Mike: This is what we say on our website about our work to protect babies fed on formula: "Breastmilk substitutes are legitimate products for when a child is not breastfed and does not have access to expressed or donor breastmilk. Companies should comply with composition and labelling requirements and other Code requirements to reduce risks - independently of government measures. Parents have a right to accurate, independent information. Baby Milk Action is not anti-baby milk. Our work protects all mothers and infants from irresponsible marketing."

I don't know if that is sufficient, particularly given question two, where I've explained in greater detail some of the ways our work does protect babies fed on formula. But perhaps I should say something about 'judging mothers'. I have argued in the past that no mother should be made to feel guilty about how she decides to feed her child - and some people have taken issue with me about this, sometimes arguing, for example, that we make mothers (and everybody else, for that matter) feel guilty about smoking, so why not try to dissuade use of formula with similar tactics?

My short answer is I don't think it does nobody any good - except, perhaps, making some breastfeeding advocates feel superior. In my view, mothers use formula either because they weighed up a whole host of factors and made the decision they thought was right for them and their baby, or because they were misinformed and thought formula is the same as breastfeeding (or even better than breastfeeding given some promotional claims and sensationalist media articles) and so it wasn't an issue. In both cases, why load guilt on to the mother?

Q.Funnysinthegarden: Along with other posters, I too am uncomfortable with this discussion. I'm afraid that BMA and its followers really do appear to be anti-formula, and to me that is unacceptable. I am not sure if politically it is wise for Mumsnet to host a chat with an organisation which holds such one sided views. Of course they say they support both types of infant feeding, but a glance at their site would suggest otherwise. Incidentally, why is a man fronting this campaign. Surely there are many women who would be better placed to do so?

A.Mike: Baby Milk Action's focus is 'protection'. We work for products to be marketed appropriately as I have explained in my answers to questions two and five, and that is to protect both breastfeeding and babies fed on formula.

The protection we have achieved for mothers and carers who use formula is real. For example, if it was not for the work we have done with our partners at the European Union, the Codex Alimentarius Commission and elsewhere, the limits on the levels of pesticides in formula would be higher than currently permitted, inappropriate ingredients would be more common and marketing even more bogus and aggressive [more details given on my blog].

Regarding your question, there are no doubt many women who could do a better job than I, but when I was interviewed for the job back in 1996 I was considered to be the best candidate for the job. Gender was obviously not a defining requirement. My colleague, Patti Rundall, our policy director, is a woman and she is extremely able and knowledgeable. Indeed, it is Patti who argues on behalf of mothers and babies at the European Commission and Codex Alimentarius for improvements to the safety and composition of formula.

Q. Tabbouleh: How did you get involved with BMA?

A. Mike: I worked in Malawi, Africa, for four years in the 1990s. Baby Milk Action was advertising for a Campaigns and Networking Coordinator on an initial six-month contract when I arrived back and I've not been able to leave since!

Q. Tabbouleh: What practical actions can MNers do to support BMA and are there any tasks which MNers could volunteer to help out with?

A. Mike: Join our email alert list if you have not done so already, then you will receive information about campaigns, events and developments. We ask the public to send messages to companies that are violating the Code and Resolutions, and in the context of the UK to report violations to us, Trading Standards and the Advertising Standards Authority. The best way to do this is via the Baby Feeding Law Group website.

We have various resources available in our online virtual shop, which help to fund the campaign and are a useful source of information on infant feeding and holding corporations to account. Of course, there is a mass of free information as well. We also welcome people to join Baby Milk Action as members. Members receive our newsletter and year report, and elect the board of directors at our AGM.

Q.Tabbouleh: How can we launch an effective campaign to ensure healthcare practitioners know, understand and communicate the safe methods of preparing formula?

A. Mike: The newest addition to our resources is a DVD, Infant Formula Explained, which consists of a film for health workers and a film for parents who are intending to use formula. This is available for health facilities to use under an annual licence.

It explains the different types of formula on the market and how to reconstitute powdered formula in line with World Health Organisation and Department of Health guidance There are an increasing number of other printed resources available on formula from independent, objective organisations, such as UNICEF and the Department of Health.

Q. Lyns12: What you would suggest to a mother who does not want to use formula but still requires, for whatever reason, milk to supplement her own?

A.Mike: We do not give advice to mothers, other than in line with international recommendations. If a mother is breastfeeding a child under six months of age and believes this is insufficient for her child, the first step should be to check this out to see if it really is the case and, if so, if she can change how she is breastfeeding to increase supply.

If she is wanting to supplement and not use formula, then there may be an option of breastmilk from a donor milk bank. This is generally intended for premature babies, but milk banks may have milk available for older babies, but it is unusual. The Global Strategy for Infant of Young Child Feeding states: "For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant's own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances."

I am aware of internet sites that link mothers. These are most active in the United States and Canada. There are risks with feeding unpasteurised milk from a stranger found through the internet (and risks in meeting strangers in general through the internet, for that matter). I was discussing this with an adviser the other day, and we really need to see some clear statement and guidance from our health professional bodies for anyone who is planning to go this route. A statement has been made by our partners in Infact Canada.

Q. HermyaTheRedNosedReindeer: I've come across some healthcare professionals who aren't as clued up on breastfeeding as they are on formula feeding. The information is so readily available to those who want to find it - do you think there is any way of correcting the inbalance that seems to exist in some quarters?

A. Mike: I would suggest that these healthcare professionals are not that clued up about formula feeding either as they will probably have received the information they have about formula from company reps. Remember, Baby Milk Action and others have won various cases at the Advertising Standards Authority (ASA) against the formula companies for making untrue claims about their products in advertisements. The information health workers receive is actually unregulated, because when we have reported misleading advertising to the ASA, it has refused to investigate, on the grounds health workers are more expert than they are.

Regarding breastfeeding, it is surprising how little information there is about breastfeeding on medical courses, which is one obvious place where this needs to be addressed. [My longer answer has information on sources of independent information.]

Q. Organiccarrottcake: How can the marketing of formula properly be controlled in the UK when the only apparent organisation to control it, the ASA, is a toothless waste of time. As it stands, if an advert is found to breach the regulations (such as the big-cup advert) the company is simply told to stop running it. Often they don't (I've seen this advert since its ban, despite C&G telling me they were not running it again) and even if it isn't run again there's no requirement for retraction so viewers simply assumed it's run its course.

A.Mike: The ASA could do more than it does. It takes a very narrow view of company responsibilities under the Advertising Code. Adverts are supposed to be 'legal, decent, honest and truthful'. Even though UK law is narrow, the International Code says that companies should ensure their practices at every level are in accordance with its provisions independently of government measures. Therefore, 'decent, honest and truthful' advertising should be in line with the Code and Resolutions. I've not been able to convince the ASA of this logic as yet - but then it is funded by the advertising industry. [My longer answer explains why successive governments have still not implemented the international marketing standards in the UK.]

A. Mike: Formulas sold on the UK market have all ingredients that are known to be beneficial and necessary for babies. Some companies add extra ingredients and make health claims about them, but these claims do not stand up to scrutiny.

[In my longer answer, I talk about some of the health concerns raised over optional added ingredients such as long-chain polyunsaturated fatty acids (LCPs).]

So, yes, I very much agree there should be pre-approval involving studies conducted in the public interest, not just by formula companies. If an ingredient is found to reduce the shortcomings of formula, then it should be added to all products (unless there is a possibility of an adverse reaction in some infants). These ingredients should not be used for promotional purposes, and if there is the possibility of some babies reacting badly to them, there should be a warning about this.

Q. Jean Kelly: A lot of people are unaware of the risks of using formula so can't make an informed decision when deciding how to feed their babies. Do you think formula should be labelled with the health risks like tobacco boxes are?

A.Mike: Warnings are important, but I think there is also a pressing need to get rid of health claims on formula. My view is we should treat formula for what it is: a nutritional medicine. Get rid of the polar bears and bright colours, free gifts and baby clubs, and have it available for those who need it, but without the hype.

[In my longer answer I talk about health warnings in other countries, and what happened when Baby Milk Action was asked to help design a label for infant formula.]

Q.cuppateandjuice: Powdered formula is impossible to make and store in a sterile manner, and therefore liquid formula is theoretically 'safer' in terms of potential hazardous contents.
Why, then, is there no concentrated sterile liquid formula product available on the market which can be diluted with cooled boiled water to provide a safer drink for babies.

Are current liquid sterilisation/pasteurisation techniques effective enough to allow a bottle of concentrated liquid formula to be kept in a fridge and used safely for a number of days? Are any formula companies looking into such a product or would it not be viable?

A. Mike: This is an interesting question. We've worked a lot on how to reduce risks from possible intrinsic contamination of powdered formula. Concentrated sterile formula is available in the US, at least, for diluting in the ratio 1:1. So volume wise, it is not a great convenience. It is a little cheaper than ready-to-feed, but more expensive than powder. The big concern in the US is the risk of it being fed concentrated, which overloads the child's organs with minerals.

I've been filming reconstituting powdered formula with a couple of mothers in recent weeks for our Infant Formula Explained DVD. Though it is a bit of a pain to have to cool the bottle after it has been reconstituted with water above 70°C (to kill any bacteria), it is not much more inconvenient than mixing up a bottle is. Unused formula should be discarded after use, but prepared bottles can be kept in the back of the fridge, at a temperature no higher than 5°C, for up to 24 hours, for later warming. For the film, we have followed the guidance available on the World Health Organisation website.

Q.Himalaya: Do you think that the other baby milk companies which also violate the marketing code are relieved that the singular focus of the campaign on Nestlé takes the heat off them? Is there any competition among baby milk companies to be recognised and seen as the most ethical in marketing, or do they all keep their heads down to stay out of the way of bad publicity?

A.Mike: If you visit our website, you find reports and campaigns on other companies. Danone is an increasing problem since it took over the NUMICO companies: Nutricia, Milupa (which includes the Aptamil brand) and Cow and Gate.

We look to the Breaking the Rules reports produced by our partners in the International Baby Food Action Network (IBFAN), led by the International Code Documentation Centre (ICDC) in Penang, Malaysia. Nestlé systematically violates the International Code and Resolutions, more so than any other company in terms of volume and the provisions it breaks, which is why it is targeted with the boycott. According to industry analysts Nestlé currently controls about 29% of the global baby food market.

Danone has jumped to 15% market share and in the last monitoring report in 2007 the combined violations of it and its new companies rivalled Nestlé. However, as Danone had only just bought the companies, we contacted the management and asked them to sort out the marketing practices of their new companies. Unlike Nestlé's dismissive response, Danone executives promised a 'root-and-branch review', and we gave them credit for this.

However, a new monitoring report has just been produced and, if anything, Danone's 'review' has made things worse, not better. [In the long answer I talk about what happens next with Danone, and the experience of a company that decided it wanted to comply with the marketing requirements.]

Q.Scrappydappydo: Do you think the boycott of Nestlé is having an impact? I haven't brought Nestlé products for 10 years but sometimes wonder if its worth it as they are such a huge company - not sure if little old me makes much of dent (not that I'll stop the boycott).

A. Mike: From everyone who has made a dent, we have collectively sculpted Nestlé into the most boycotted company in the UK by far and one of the four most boycotted companies on the planet - according to independent analysts GMI. [Longer answer has information on some campaign successes and our experience of communicating directly with Nestlé executives.]

What makes Nestlé take notice is a hit to its profits and public image. Our job is to increase the pressure and exposure to force movement, which has happened time and again. Nestlé has also tried to improve its image by launching a Fairtrade KitKat. This involves just 1% of the cocoa Nestlé purchases. At the same time, it has failed to deliver on a promise made in 2001 to stop child slavery in its cocoa supply chain within five years (by 2006).

Campaigners in the US have taken Nestlé to court on behalf of children who were trafficked to farms supplying the company. There are also concerns over the source of palm oil in Nestlé products and the destruction of Indonesian rainforests to produce it. This was targeted in a Greenpeace campaign this year and Nestlé has said it will change its suppliers of palm oil - within five years.

The more people who boycott Nestlé and tell the people who run the company, the more influence we have. So it would be great if everyone who reads this goes to our site and clicks on the 'email Nestlé' link.

Q.Lactivist: How can I get across to people that it is important to boycott Nestlé? My son's school seems to think it is something that happens abroad and nothing to do with us.

A.Mike: I think I've answered this one above in terms of how our action here has an impact. Practically, we have leaflets, credit-card sized boycott lists, Nestlé - No Thanks cards, posters and so on. There are various DVDs that could be shown in school. It may also be possible for us to arrange a speaker to come in, or we can help with a presentation. We do also offer to come to debate the issues with Nestlé and this has happened in a few schools, but Nestlé now refuses to take part. It is still worth asking, however. They may surprise us.

Q. Maisyandpanduluce: I live overseas. Nestlé is ubiquitous - in the way that, oh I don't know, bread, is in the UK. Any hints for boycotting things here?

A.Mike: The main focus of the boycott is Nescafé coffee, its flagship product (though it depends on which country you are in). So that is the easy way - find an alternative coffee, tell Nestlé you are boycotting and spread the word to your friends and colleagues. We produce various materials to help with this.

With other products, I would be very surprised if there are not alternatives for confectionery, cereals etc. or whatever processed food you are looking to buy. If you are somewhere where Nestlé brands are used, that is an opportunity to raise the issue, if you feel comfortable doing so. If not, leave a leaflet or card behind!

We are launching a new campaign shortly, called Nestlé - Good Grief! (Nestlé has the slogan, Good Food, Good Life, and we want people to think of what is not so good about its business activities). So watch out for resources to promote the Nestlé - Good Grief! message. It would be great if it becomes something people say automatically when Nestlé products appear.

Q. Milamae: Do you think the use of formula in developed countries is over-demonised in order to protest against its use in developing countries? Can you see how this alienates many parents and do you think a different approach would be more beneficial?

A.Mike: These are very interesting questions, that need a bit of unpacking - thank you for asking. First, is 'the use of formula' over-demonised in developed countries? Well, I've seen there is a Facebook group called, "It's baby formula - NOT POISON", which I think shows us that some feel it is. Of course, formula is the opposite of poison - it is a nutritional medicine that is better than the other alternatives if a mother's milk or safe donor milk is not available. Do those who feel formula has been demonised think this has happened because of the situation in conditions of poverty? Conditions where babies fed on formula are not only more likely to become sick than breastfed babies, but more likely to die? Possibly, and pictures such as the famous one of a mother with twins in Pakistan are upsetting (I'll talk about that more elsewhere).

However, in my experience talking with mothers and carers, those who are angry about the way formula is sometimes talked about are angry because of what is said about it in the context of developed countries. This anger is fuelled by certain sections of the media that report infant feeding stories through the prism of the 'bottle feeding vs breastfeeding' debate, and love to highlight studies or comments that challenge the 'breast is best' message.

I vividly remember a friend saying that even seeing the 'breastfeeding is best for babies' message on formula labels was like a knife through her heart, because she had wanted to breastfeed, but her child was not taking her milk. She didn't want reminding breastfeeding was better than formula, she wanted to be told the formula was just as good.

But formula is not just as good as breastfeeding, from a health point of view. Should we cover up that truth? I think we need to treat parents and carers like grown-ups and let them make decisions based on accurate information. I won't go through the health issues here, partly because I may be attacked simply for relaying information from expert health bodies who are unequivocal that babies who are not breastfed are more at risk of short and long-term illness and sub-optimum development. These are scientific facts, not Baby Milk Action's opinion.

But the difference in both the short and long term health outcomes is real. The NHS spends millions treating extra cases of illness attributed to babies not being breastfed. The problem in developing countries is sometimes seen as just due to poor water or hygiene, but the more critical issue is denying babies the protective effect of breastfeeding - when they become sick, as they are more likely to do, they may die without the benefit of the treatment babies have access to in the UK.

While babies in the rich world are unlikely to die, and anecdotes can be cited of healthy formula-fed babies and sickly breastfed babies, short and long-term health differences appear in studies of large groups of breastfed and formula-fed people. Although there is overlap, people fed on formula, as a group, have poorer health outcomes than those who were breastfed.

Being objective about the risks of formula is important and mothers should be supported and encouraged to breastfeed. But for the mothers and carers who use formula, Baby Milk Action is working to ensure clear, accurate, unbiased information about formula is available to stop parents being misled and ripped off by companies hyping their formula as the 'best'.

We aim to highlight key facts that people who use formula - a nutritional medicine, remember - need to know:

If using formula, price is as good a reason as any for choosing a brand - more expensive formula is not 'better' than other brands.

All brands of infant formula on the market must comply with composition requirements and so contain what is known to be necessary for babies. Optional ingredients are not compulsory simply because they have no proven benefit.

Goat's milk should not be used (it is illegal to sell it).

Soya milk should only be used on medical advice.

You can switch brands to see if your child seems to like one more than another if you like (they do taste different, if you fancy giving them a go).

If using formula, it is best to use the whey-based milk for use from birth for the first 12 months, until normal cow's milk can be used.

Milks for so-called hungrier babies are not only unnecessary, there is no sound evidence to show that their casein base is more satisfying to babies.

Follow-on milks are unnecessary and were introduced to try to get around the restrictions on advertising infant formula - any additional iron, protein or other nutrients a child requires will be amply supplied by a normal weaning diet from six months of age.

So-called Good-night milks should be avoided - there is no evidence that they help babies to sleep and a baby's teeth should be cleaned after being fed with them, which will wake the baby up.

And, as I've said at greater length above, every drop of breastmilk counts, every feed counts, so don't believe that formula feeding has to be exclusive (unless HIV is an issue, when mixed feeding is the most dangerous approach).

Two other points, when these 'breastfeeding vs bottle feeding' stories break in the media challenging the 'breast is best' message, we look into them to see if they have substance - and without exception, they do not. Sometimes there is a formula company connection, sometimes it is a journalist putting a spin on a story because they know it will attract attention, sometimes even a scientist is speaking outside their area of expertise to draw attention to other research. There are case studies examined on our website.

Second, it is best to look at independent information on formula, rather than company websites (UNICEF and mother support groups such as the NCT have information for mothers who use formula). If you do look at company information, pay close attention, because they are very sneaky, particularly in countries where there are some regulations, even if weak. For example, look at what companies say about LCPs (which I've talked about elsewhere). They say these are in breastmilk and are thought to have benefits. They want the reader to make the jump to thinking formula with LCPs also has benefits, but the evidence to date shows that formula with LCPs is no better than formula without LCPs.

With other ingredients over which claims are made, it is sometimes necessary to look at the research in depth. We and others have asked the ASA to do so on a number of occasions and they have found various claims cannot be substantiated, such as the claim that 'prebiotics' in formula build the immune system. Prebiotics are properly called oligosaccharides. Formulas contain a handful of synthesised oligosaccharides, whereas breastmilk contains over a hundred.

So the sad fact is that the claims that give some people comfort about using formula are either not what they appear or are outright dishonest. Unfortunately, when we point this out, Baby Milk Action is sometimes attacked for 'demonising' formula, when those who deserve to be criticised are the companies that knowingly and deliberately mislead to increase their sales and profits.

Q.snugglepops: I am interested in inappropriate formula feeding during disasters and the aftermath, such as Haiti. How do we ensure that aid money we give is not used to provide formula and thereby increase the suffering or babies and children at such a difficult point of their lives? Is formula safe only in countries with good water supply, good standard of living, hygiene etc?

A. Mike: Baby Milk Action set up an ad hoc committee with the UK development agencies in the 1990s to address the issue of infant feeding in emergencies. There had been some devastating situations, such as the Armenian earthquake in 1988, where breastfeeding rates fell from 64% to 20% after the country was flooded with free supplies. The ad hoc committee drafted policy guidelines, which have since been introduced by the development agencies. The Emergency Nutrition Network was part of this initiative and has developed training modules for field staff and also has information for members of the public.

The basic advice to the public is it is better to send money than formula. Any formula is best acquired locally where it should be labelled in the correct language. [Experience of supporting people in emergency situations is given in the long answer].

Regarding 'safety' of formula, it is a nutritional medicine and should be treated with appropriate respect, which includes understanding its limitations. It is not a living substance, it does not contain the same constituents as breastmilk, those it does contain are not necessarily absorbed or used in the same way as those in breastmilk and babies fed on it are more at risk of short and long-term illness. Powdered formula is not sterile and may contain harmful bacteria and so must be used in accordance with WHO guidance to reduce risks.

There are additional risks where water is unsafe. Not only is the child denied the protection provided by breastmilk, it may be exposed directly to infection through the feed. The big killer, however, is lack of treatment when babies get sick. In the UK, the illness is treated. In poor conditions it may be too late.

Q. Himalaya: As I understand it from UNICEF stats, the majority of babies in the developing world who are not exclusively breastfed are not given other milk or formula, but water or complementary foods traditional in that community such as maize meal porridge.
So the challenge of enabling more women to exclusively breastfeed for longer and save the lives of 140 million children a year is not simply one of breastmilk vs formula (or of poor people vs big corporates) it is also about challenging some of the traditional practices handed down from older generations.

Do you think that there is any hope that a company such a Nestlé could be a force for good? They have has so much marketing expertise, scientific research and global reach, and an interest in selling products to children and families throughout their lives - do you think there is any hope that they might become a force for good in promoting sound nutrition, from breastfeeding to eventual weaning and beyond. Do you see any sign of companies doing this?

A. Mike: I'm not sure that you have interpreted the information on the UNICEF site correctly. This is what UNICEF states on that site:

"It has been estimated that optimal breastfeeding of children under two years of age has the potential to prevent 1.4 million deaths in children under five in the developing world annually. Yet early cessation of breastfeeding in favour of commercial breast milk substitutes, needless supplementation and poorly timed introduction of solid, semi-solid and soft foods, often of poor quality, are far too common."

WHO and the Lancet published the Child Survival series looking at interventions that could most effectively prevent under-five deaths and breastfeeding came out top, potentially preventing 13% of under-five deaths in the 42 countries where most occur. Appropriate introduction of complementary foods could prevent a further 6%. These interventions could save more lives than universal provision of safe water, adequate sanitation and vaccination.

Commercial breastmilk substitutes are not the only problem, as you say. Water, teas and juices are sometimes introduced to needlessly supplement breastfeeding during the first six months. Sometimes inappropriate milks are used. We have campaigned for a long time calling on Nestlé, the market leader, to stop promoting its powdered whole milk in the infant feeding sections of pharmacies and supermarkets, but it continues to defend this practice, even though it knows mothers who cannot afford formula may buy the whole milk along the shelf, which is typically a third of the price.

As UNICEF has said in the past: "Marketing practices that undermine breastfeeding are potentially hazardous wherever they are pursued: in the developing world, WHO estimates that some 1.5 million children die each year because they are not adequately breastfed. These facts are not in dispute."

Certainly it is true that harmful traditional practices and use of other substances need to be challenged. But I disagree that the 'expertise' of Nestlé should be called on to assist in this - other than improving conditions for their own staff, in line with International Labour Organisation Conventions (the issue of maternity rights is another area where Baby Milk Action and our partners have worked).

Where we have seen Nestlé and other companies involved in breastfeeding promotion it has, at the very least, been used to try to divert criticism, but has also been used to undermine breastfeeding by the images selected, the language used etc. This has been documented in the Breaking the Rules reports by our IBFAN partners.

Until these companies act on their obligations as required by Article 11.3 of the International Code of Marketing of Breastmilk Substitutes, it is a mistake to even think of involving them in breastfeeding promotion programmes - indeed, the World Health Assembly has adopted Resolutions saying that conflicts of interest should be avoided in this area.

There is a reason to be hopeful, however. Over 60 countries have regulations of some sort. Countries such as Brazil and India have implemented the Code and Resolutions fully in legislation and banned the promotion of breastmilk substitutes and baby foods. The fact that companies can comply when forced to do so demonstrates that we are not asking them to do something that is impossible. They simply don't want to comply because they know that breastfeeding rates increase, which means less sales for them.

Again, look to the evidence. Independent industry analysts Euromonitor said in 2008: "There are significant international variations in the regulations governing the marketing of milk formula, which are reflected in sales differences across countries." And: "The industry is fighting a rearguard action against regulation on a country-by-country basis."

We need to defend the regulations for the benefit of all babies, whether breastfed or fed on formula.

Twins photo

I have seen that there was a discussion about the famous 'twins' picture used on a postcard sold by Baby Milk Action. I have explained the background to this picture and the issues it raises in my long answers.